The NHS Should Make and Sell its own Homeopathic Remedies and Homeopaths Should be Paid the Minimum Wage

In March this year I blogged on the topic of NHS funding for homeopathic remedies. Even though I agreed with the critics of homeopathy, that there is no credible evidence for the efficacy of homeopathic remedies and that it is irrational to use these in preference to medical treatments that have actually been proven to work, I argued that the NHS should continue to subsidise the cost of homeopathic remedies. My basic line of argument was anti-paternalist. People should have the choice to be irrational if they want. What is important is that people are provided with all information relevant to their decision making. However, if they go ahead and choose to behave irrationally, then, provided that they are not harming others, their actions should not be interfered with. It is not the State’s role to prevent people from making such choices.

It might be objected that while it is not the State’s role to prevent irrational choices, it is not the State’s role to support such choices either. I agree, however the State also has a duty to spend money wisely and limit its demands on taxpayers. In circumstances where the use of homeopathic remedies is actually cheaper than conventional medical alternatives then the State should be willing to subsidise the use of homeopathic remedies so as to save money on the cost of subsidising conventional medical alternatives. It is pleasing to see that the NHS agrees with the gist of my argument. In a recent press statement, the ‘NHS Knowledge Service’ has affirmed both that there is no evidence that homeopathy works and that homeopathic remedies should continue to be received on the NHS (subject to the recommendation of local doctors). The decision is justified on the grounds of the importance of patient choice. See: http://www.nhs.uk/news/2010/July07/Pages/nhs-homeopathy.aspx

The press statement also notes that the NHS spends somewhat between three and four million pounds per year on approximately 25,000 homeopathic items. That is an average of £140 per homeopathic item. Presumably much of this cost is spent on staff costs and only some of it is spent on ‘homeopathic items’, which seem to include pills, ointments, gels, crystals and small dropper bottles of extremely diluted liquid. The NHS had a responsibility to spend the money in its budget wisely. If, for example there is a choice of two homeopathic remedies that are available, each of which is equally effective, then the NHS has a responsibility to fund the cheapest of these only. Similarly if there are two homeopaths available to provide a homeopathic remedy then the NHS should only agree to employ the cheapest of these. To do otherwise is to throw away money needlessly that could be used on real medicines that actually work instead.

Given that the NHS concedes that there is no evidence that homeopathic remedies actually work, it implicitly also concedes that there is no evidence that homeopathic training makes any difference to the efficacy of homeopathy. Therefore, it follows that the NHS should be indifferent to employing either trained or untrained homeopaths. The overriding consideration should be cost. The NHS has a responsibility to employ the cheapest available people willing to act as homeopaths and should redirect money saved to use on actually effective medical care. The NHS should offer minimum wage to homeopaths. If currently employed NHS homeopaths are unwilling to work for the minimum wage then they should be replaced by members of the currently unemployed and untrained who are willing to work for minimum wage. Similarly the NHS should save all that it can on the costs of acquiring homeopathic remedies. Homeopathic remedies must be extremely cheap to manufacture in bulk, given that they are created by diluting an active substance in vast quantities of water, and should not cost more than a few pennies each. If suppliers cannot be found who can produce homeopathic remedies at competitive prices then the NHS should make its own cost effective homeopathic remedies. The NHS is right to support patient choice, but it is outrageous that £3-4 million a year are spent on homeopathy when a similarly effective service could be provided to patients at a small fraction of this cost.

42 Responses to The NHS Should Make and Sell its own Homeopathic Remedies and Homeopaths Should be Paid the Minimum Wage

the problem with this argument is that people use homeopathy and desire it because they think that it works. Your cost-saving suggestions would only actually save money if they preserved those features of homeopathy that make people think that it will benefit them.

The evidence for homeopathy is not that it is no better than *nothing*, but rather that it is no better than placebo. A large part, potentially all of the benefit of homeopathy relates to the placebo effect. And for homeopathy (as for conventional medicine), the placebo effect is mediated by the interaction that patients have with the person giving them treatment, and by their confidence that the treatment will actually help them. Specifically, one reason why people may prefer to go to a homeopath is the willingness of the practitioner to sit down and listen to them, to provide a plausible (to the patient) explanation of their condition, and to select a treatment that plausibly (to the patient) will benefit them. These elements are derived from the homeopaths’ training.
If, instead of a trained homeopath, the patient is confronted by someone from the ranks of the recently unemployed, with no particular skills in counselling and listening, and no particular empathic (or salesmanship) skills, it is much less likely that they will believe that they are going to benefit from the treatment. Similarly, the NHS brand of ‘water’ may well be much less alluring or convincing than a homeopath’s more expensive preparation. (The expense may be part of what convinces that it is actually beneficial).

The risk of your proposal is that it will force people to private (trained) homeopaths outside the NHS. (Which isn’t necessarily a problem in my view). But it may also drive them back to the queues in their GP and emergency department, obviating any cost saving.

In the spirit of Steve’s post and wanting to endorse the maintenance of choice for workers as well as patients, interested parties might be intrigued to know that NHS Tayside has recently advertised for a very well paid homeoquack. Sorry I mean homeopath.

Given Steve’s claim, which is no doubt correct, that an admission by the NHS that homeopathy does not work is tantamount to an admission that training does not matter, there has been a move on t’interweb to encourage people to apply for this job. The level of pay should certainly appeal to poorer paid academics.

Once you have wiped the tears of laughter from your eyes, I’m sure you will agree that all of these candidates are eminently qualified for the post of homeoquack. And, if the package does indeed look more attractive than an academic post, one can always apply for the job here:

Muireann I’m astonished that a homeopath can be paid so much. Under my proposal savings of up to 55,000 pounds per homeopath per year can be expected.

Dominic, the NHS’s case for providing homeopathic remedies was based on patient choice, not patient choice that happens to be as effective as placebo, so in one sense your line of reasoning should not really be relevant to them. But suppose that we were concerned to ensure that the NHS provides homeopathic services as good as placebo (or better). it might be the case that the untrained tend not to do this but we’d need evidence to back this claim up. In any case, they are unlikely to need two to four years of training, which is what homeopaths curently seem to get. Perhaps a weeks worth of basic counselling training will be sufficient. A further problem is that some current NHS homeopaths may be worse than placebo and by your reasoning they should not be supported by the NHS. As for the NHS product, I propose – well I suspect that a fancy name and a nice label will allay the irrational fears that are of concern here.

“In circumstances where the use of homeopathic remedies is actually cheaper than conventional medical alternatives then the State should be willing to subsidise the use of homeopathic remedies so as to save money on the cost of subsidising conventional medical alternatives.”

If homeopathy is proven to be no more effective than placebo, then isn’t this statement like saying “The government could save cost on it’s programs by administering placebos instead of real medicine”? How is it ethical to prescribe a placebo when you know that the patient has a real issue and it’s outside of the context of a study on the efficacy of medicine?

To start, a little paternalism in medicine never hurt anyone, feelings notwithstanding.

More importantly, I think that Steve has shot himself in the foot here. One does not need to appeal to paternalism to argue against funding homeopathy. Let us consider the following:

Premise 1: “if [people] go ahead and choose to behave irrationally, then, provided that they are not harming others, their actions should not be interfered with”
True
Premise 2: “It is not the State’s role to prevent people from making such choices”
True
Implied Premise 3: Patients using public funds does not harm harm others
Conclusion: The NHS should subsidize homeopathic nostrums.

This argument is not sound.
The implied premise 3 is profoundly false. Given that “the NHS spends somewhat between three and four million pounds per year on approximately 25,000 homeopathic items,” and that “the ‘NHS Knowledge Service’ has affirmed … that there is no evidence that homeopathy works” It follows that the this money could be put towards interventions of proven efficacy and that diverting these funds towards over-priced water effectively harms, beyond the effects of placebo or any purely experiential considerations, patients that depend on these interventions. 4 million pounds goes a long way for people suffering from disease.
Furthermore, the presence of state funding for homeopathy gives an aura of authenticity and efficacy to the practice that simply does not and cannot deserve. The average patient cannot be expected to go through PubMed in search of evidence of efficacy of homeopathy or to understand fully the difference between placebo effect and actual benefit. The average patient will take NHS funding as a stamp of approval and thus be effectively mislead, away from proven medical interventions.

In the end, it is simply false to claim that no one is harmed by public funding of homeopathy, indeed homeopathy generally. The crucial premise is false and the conclusion does not follow. There is no good decisive reason for a public institution like the NHS to fund homeopathy. This does not prevent patients from choosing homeopathy, it simply places the burden of their dubious decisions squarely on their own shoulders.

Just a quick comment on scientific rigour in response to the links posted by Dr Malik. None of the articles the reader is directed to give anything like a whole hearted endorsement of homeopathic remedies: two of them say that conclusions cannot be drawn either way because of problems with methodological quality; one gives cautious support, but for reasons outlined below one ought to be sceptical.

(i) the study itself does not wholly endorse an effect above placebo and says there is “insufficient evidence from these studies that homeopathy is clearly efficacious for any single clinical condition”

(ii) a rather long correspondence in took place in the Lancet in the wake of this article where many problems with it were noted. However, one of the most problematic issues for the rigour of the study was that the individual studies included in the meta-analysis were all methodologically weak themselves and often, not just weak, but deeply flawed. For this reason, the subsequent results from the meta-analysis cannot be taken to say anything on the matter one way or the other.

(2) The first BMJ article cited ‘Clinical trials of homoeopathy’ by Kleijnen et al.
For similar reasons that plagued the Lancet study this article did not give a ringing endorsement of homeopathic treatments. The article itself states that there is “not sufficient to draw definitive conclusions because most trials are of low methodological quality and because of the unknown role of publication bias.”

(3) The second BMJ article cited ‘Randomised controlled trial of homoeopathy versus placebo in perennial allergic rhinitis with overview of four trial series’ by Taylor et al.
While the article itself gave a cautious endorsement of an effect above placebo the commentary and the other rapid responses which followed it made points which ought give the scientist and doctor pause for thought.

(i) the study sample was very small. As a result it is not really possible to interpret the results of the study one way or the other. The effect could be random variation.

(ii) the study was supposed to be on those with allergic rhinitis but there are questions over whether the individuals in the study were actually correctly diagnosed with the target disorder. As such, subsequent improvements measured are to be questioned.

(iii)the issue of publication bias was not addressed over the four trial series.

There are further problems afflicting all of the studies pointed to, but to go on would have me here all night. It is not enough when seeking scientific support for homeopathic treatments simply to direct the reader to studies in reputed medical journals. One not only has to see what the studies themselves actually say, but also has to assess the methodological quality of the meta-analyses and their individual studies. If this is found wanting, then the results of those meta-analyses must also be found wanting.

As to the supposed evidence in support of “Homeopathy” and in reply to Dr. Malik, I can only say that all studies of this kind are fundamentally flawed from conception onwards, for one simple reason: testing homeopathy in patients is the equivalent of putting the cart before the horse. As the commentary following one of the papers correctly states : “Unlike many medical interventions, there are no established animal models, mechanisms of action, or examples of similar treatments of proved benefit … homoeopathy is biologically implausible because of the use of medicines diluted beyond the Avogadro limit.” (http://www.bmj.com/cgi/content/full/321/7259/471?view=long&pmid=10948025)

Where the commentator and every researcher that has thus far wasted his time on homeopathy go wrong is to insist on “a high level of randomised evidence before concluding that homoeopathy exerts specific effects.” What we need is a coherent, robust theory of how such a thing could even begin to work within the physical world that we inhabit.

If homeopathy wants a fair hearing, it must play by the rules. Not the rules of “toxic, patriarchal, oppressive Western medicine” but the rules of physics, chemistry and biology, ie the rules of the Universe. To be taken seriously proponents should show the same respect for science as any decent scientist and human being would: show us a coherent and plausible mechanism of action; show us a coherent and plausible animal model; give us supporting evidence of similar treatments.

Pharmacological firms adhere to these standards, why shouldn’t homeopaths? Imagine, if you will, if Pfizer simply concocted a drug out of thin air and went strait to clinical trials, relying on nothing more than the “law of similars” or mystical energies for justification.

If homeopaths are unwilling or unable to play by reality’s rules, they are free to pack up their toys and go to their own sandbox. What they cannot do is play Doctor.

I would like to see Steve’s response to Dmitri’s arguments suggesting that state funding for homeopathy causes harm. I’m inclined to agree with them. Where I disagree with Dmitri is in his suggestion that it is somehow illegitimate or pointless to conduct clinical trials on remedies that are based on theories inconsistent with modern science. Personally I would be very interested if such trials were to convincingly show an effect above placebo. I’m not suggesting that the state should pay for such trials, although I think would be preferable to actually paying for the remedies themselves.

What is much more interesting than homeopathy per se is the placebo effect itself, and in particular on which it is possible to replicate its effect without the deceipt and/or encouragement of false beliefs that goes with it. In this context I have found positive thinking, meditation, positive pscyhology and (self-)hypnosis to be extremely effective. This would be a much better investment on the part of the NHS than encouraging the false beliefs associated with homeopathy.

My line of reasoning depends on a hidden premise, but not the one you mention. The hidden premise is that if people didn’t use homeopathic remedies then they would tend to use conventional medicine instead. If conventional alternatives are more expensive, on average, then the NHS saves money by paying for homeopathic remedies rather than paying for conventional medicines. Of course these savings will be all the greater if homeopathic remedies are even cheaper – hence my push for a lowering of the cost of homeopathy. The mnoey saved can be used for any number of good purposes, helping rather than harming others.

Thanks Steve. I’d still be interested to know your position on the question as to whether subsidising homeopathy causes harm by encouraging false beliefs, and if it does, why you don’t see this as outweigh the alleged benefits. I’d also be interested in your view on whether the monies could be (even) better channelled into promoting and subsidising well-researched psychosomatic remedies that mimic the placebo effect but without encouraging false beliefs.

as far as I can see subsidising doesn’t encourage false beliefs, unless people start with the false belief that if something is subsidised then it must be efficacious. However, the NHS’s attempt to explain its position is a bit ham-fisted. Having made the decision to support the view that there is no evidence for the efficacy of homeopathy they then go on to try to be even handed in their discussion of homeopathy and this well-meaning even handedness does seem to encourage the false belief that homeopathy is on a par with conventional medicine, so to speak. As for other psychosomatic remedies – I think the NHS should be consistent and treat these in the same way that it treats homeopathy.

Does this mean you think other psychosomatic remedies (such as meditation classes) are also based on false beliefs? (Some of them are, of course, but in my opinion not all.) If not, why should the NHS treat them in the same way?

Couldn’t subsidising encourage false beliefs by encouraging practices based on them? If I take a homeopathic remedy then I’m likely to generate some kind of ex-post justification for my behaviour, given that that’s what we all do. Isn’t such an ex-post justification likely to include, at least in some cases, a reinforced belief in the principles underlying homeopathy? Also, it’s not necessary for people to belief that if something is subsidised then it *must* be efficacious, only that they believe (at some level, perhaps without even being willing to admit as much) that it is more likely to be efficacious. And I think a lot of people to have that belief.

My view is that the NHS has a responsibility to provide accurate information and to present that information in a helpful, intelligible manner. However, its responsibilities do not extend to ensuring that people do not have false beliefs. I see views that involve the claim that the NHS has greater responsibilities vis a vis people’s beliefs as being unacceptably paternalistic.

I am from Brazil, and here we have also a public national health system. We have hence the same *dilemma*: if homeopathy doesn’t have scientific support, why should we provide them for the public health system users? Why should we accept that physicians could prescribe them? This is my opinion. Actually, I agree with Steve. As far as I know, we don’t have consistent and strong evidences supporting homeopathy. But I don’t think we should forbid its use and, preserving liberty, it shouldn’t be forbidden by Law that the health system provides patients with that medical option. But my argument is somewhat different, because saving patient’s options is only a part of the argument. Since some premises are important for my argument, let me present them. We should depart here from some principles of evidence-based medicine. Since we have different *levels of evidence* (http://www.cebm.net/index.aspx?o=1025) of clinical studies, we have also different kinds and levels of *epistemic force* applied to clinical decisions. I think we all agree that a physician who doesn’t offer to his patient a medical intervention highly indicated (backed by good clinical trials or cohorts) commits a grave mistake. This is an uncontroversial example of medical negligence. Otherwise, a physician who offers to his patient a treatment contraindicated (proved harmful by the same kind of studies) acts in imprudence. But a treatment only is contraindicated if there is good and sufficient evidence that it is HARMFUL. Well, we don’t have good evidences that homeopathic treatments really work and we have some theoretical reasons against that possibility (then we should classify it within the class of “expert opinion without explicit critical appraisal”); nonetheless, we don’t have strong evidences that homeopathic remedies are harmful (we have at most some good evidences that it is without harms and benefits, but those evidences actually didn’t dissuaded homeopaths of their clinical and theoretical views). Nevertheless, if we think that homeopathic medicine has only a placebo effect, we are implicitly assuming that it isn’t harmful to patients. But it is not only homeopathy that has a placebo effect and isn’t scientifically proved; we have a lot of *allopathic* treatments that aren’t also sufficiently proved. And we still don’t know (theoretically) why some treatments work and why others didn’t. Clinical evidences don’t depend on physiological or theoretical explanations. We can have, for example, good evidences that acupuncture works in some situations, even if we don’t accept Chinese traditional medicine theoretical explanations. Clinical decisions, nonetheless, must be guided by evidences. But, should we forbid all medical treatments without good or strong evidences in their favor? I don’t think so. We should remember here that, besides treatments scientifically proved (backed up by strong evidences), we have also a lot of medical treatments without good evidences that are accepted as “possibly beneficial”. Of course, treatments that are only “possibly beneficial” cannot substitute treatments highly indicated (supported by strong evidences). It would be imprudence. But physicians cannot force their patients to follow their own opinions (even if they constitute not only medical opinion, but actually medical knowledge). Patients have rights to consent. Well, they usually have also their own opinions and views. Anyway, patients don’t have any rights against their doctors to every treatments they prefer (plausibly they only can claim treatments sufficiently proved). Hence, the patient’s right to consent doesn’t imply a right to whichever medical treatment he or she wants. Doctors, anyway, are not forbidden to prescribe treatments “possibly beneficial”. Well, both premises imply that if a patient agree with his doctor that some treatment can be beneficial, it would be wrong to forbid its prescription. But it still doesn’t imply that the government, a third party in the relation, has in this case (the case of agreement between patient and his doctor) a duty to provide the medicine; but it is not forbidden. Since the sanitary authorities can have reasons to protect patients’ preferences and opinions, unless we have strong evidence that homeopathy is harmful to patients, we have reasons for respecting and protecting patients and medical team preferences. Even if we have good reasons to think that homeopathy isn’t scientific rigorous, we should accept homeopathy as an alternative treatment in the public health system. (Excuse-me for excessive length of my comment – and some faults in my English.)

I see now that I need to check back much more often to keep on top of things. Alas, better late than never. First things first, as to Steve’s reply:
” The hidden premise is that if people didn’t use homeopathic remedies then they would tend to use conventional medicine instead. If conventional alternatives are more expensive, on average, then the NHS saves money by paying for homeopathic remedies rather than paying for conventional medicines.”

It seems to me that you are oversimplifying the situation with this premise. Not everything is about money, especially with medical remedies. I would agree with you that in the short term the NHS would probably save money by switching to homeopathy. But now we have many more questions to answer:

1) How far should we go with this substitution or subsidization policy? How does the NHS limit its support for homeopathy? It should be kept in mind that as other quack remedies homeopathy is the top contender for curing all known ailments of the human race. Once the flood gates are open, why should the buck stop with giving expensive water to allergy suffers and not extend to cancer patients? Given that your position has effectively thrown the trump card of scientific legitimacy out the window in favor of cost-effectiveness, I don’t see how the NHS would not become the National Homeopathy Service.
2) Why is simple cost-effectiveness the trump card to begin with? Should it not matter if patients are actually made better? And is it actually true that the NHS would be saving money? Efficacy should be included in the cost-benefit calculation. Conventional medicine may be more expensive but that is most probably due to the fact that it actually works (and the fact that work has been done to make sure that it does). Moreover, I would not be very confident that there will be much money saved in the long run. If you give a patient conventional medicine there is a good chance he will get better and stay that way. If you give him homeopathic water, chances are you’re gonna see him again with the same if not worse symptoms down the line. At bottom I am not convinced that even if I grant your general premise of cost-savings that the argument goes through if we take account of the long run.

I also want to respond to Peter:
“Where I disagree with Dmitri is in his suggestion that it is somehow illegitimate or pointless to conduct clinical trials on remedies that are based on theories inconsistent with modern science.”
First, I would like to say that not only do I think it pointless and illegitimate, I think it to be very dangerous as well. For the patient, for the medical profession, for society and for science.
To give some clarity, my main contention is that homeopathy, and its quack brethren of the pseudo-medicine family, are effectively jumping the gun with these kinds of studies. By seeing whether or not it (homeopathy) works and is in some way better than nothing or placebo we’re granting that there is anything to it that could be doing the work in the first place. This is, pardon the language, ass-backwards. The only reason that homeopathy is even getting this kind of consideration is because of anecdotal evidence, appeal to tradition and a healthy dose of pseudo-scientific nonsense ala “Law of Similars,” etc. These considerations do not grant it entry into the Clinical Trials Club. At best it gives reason to investigate the underlying mechanisms that are proposed.

The crucial scientific question of “How does this work?” is left dangling and instead we skip straight into testing in humans. I again want to bring up my Pfizer example. Imagine if they said something along these lines:
“We can’t really show you how or why this drug works but some guy in Europe form long ago, knowing next to nothing about germ theory or microbiology, says that if we inject this in a person with condition X it will cure him, or at least make him better. Its got something to do with miasma. We haven’t done any lab tests to see how this is possible, there have been no animal trials, but we’re certain that a popular and incoherent conception of quantum physics, although not supported by any self-respecting physicists, gives some vague idea of how it works. Or not, we’re not entirely sure. Look, the main thing is that we’re providing patients with a choice and they should not be denied this. So, can we have some public funds for our efficacy trials while we sells this to people in need of a cure or effective remedy? We’re pretty sure its different, though we can’t really say if its any better, from placebo.”
This would not stand, and for good reason. There are stages to researching medicines and they have been established through painful experience.

It should also be reiterated that no one is talking about forbidding homeopathy. As much as I am in favor of forbidding stupid behavior (and otherwise smart people often behave in very stupid ways) that is the price we pay for autonomy and freedom. The question is very different here. Should the public be forced to facilitate the stupid choices of some of its members? Even if we answer NO, as we should, this does not negate the stupid choices in question. Let them choose, so long as they bear the burdens of their decisions. As such, doctors may well discuss homeopathy as an alternative to conventional medicine and I would be fine with it (a little baffled and somewhat disgusted, but fine overall) so long as the patient pays for the little phials of water out of his own pocket and not the public purse.

Lastly, a quick note on Marco’s post. I’m afraid that you are quite mistaken in your analysis. Studies to date have shown marginal, if any, benefit of homeopathy over placebo or no treatment. True, homeopathy has not been shown to cause direct harm. But that simply shows that its is not a poison. In this regard, I agree, “Do no harm” does not forbid homeopathy.
But there is a larger context here. When a physician knows of a more effective remedy of greater overall benefit, prescribing the inferior treatment is a harm. The patient is denied the best possible care. No single study has shown that homeopathy is more effective, or as effective for that matter, than conventional medicine. Thus, prescribing homeopathy is harmful and ought to be forbidden by medical ethics. The doctrine of “Do no harm” dictates that a physician may not, in good faith, prescribe what he knows to be an inferior treatment, even at the explicit request of the patient.

Steve: I was not suggesting that the NHS take responsibility for ensuring that people do not have false beliefs. I was suggesting that they should take account of the extent to which their policies may be encouraging such beliefs. Basically I don’t think the NHS should be getting into the homeopathy business at all, except to spend minimal amount of money reviewing meta-analyses that have been funded by others.

Dmitri: beyond the above I am not suggesting that the public subsidise such studies. But if homeopaths (or indeed Pfizer-like private companies) wish to spend their own money funding them I don’t see why we should object. Science is a continual back-and-forth between theory and experiment. You are basically saying that our entire scientific world-view logically forbids homeopathy having any effect beyond placebo. I almost agree with you – but perhaps there’s something we haven’t thought of? – but if we disapprove of such studies being done (as opposed to the public paying for them) then don’t we give the impression that we’re afraid they might turn up something that challenges our worldview? If we think this is impossible, why not just let them go ahead?

Peter, private individuals are free to dispose of their private income in any way they wish. The issue, however, centers around public funds, and whether spent on research or subsidizing the purchase of homeopathic solutions is really of secondary concern.

And it is precisely that thing “we haven’t thought of” that is the issue here. Centuries of scientific knowledge and the best theories tells us that homeopathy does not and cannot work. There is no large scale, quality clinical trial that shows that it works. At best we have ambiguous and contentious conclusions from studies that raise more questions about their quality than their results. Why should we even consider it further?

The bottom line for me is that there is no coherent explanation, or even an honest attempt at one, of how homeopathy works. What is more likely, that decades rigorous scientific knowledge and the best theories of the nature of the universe are wrong, or that homeopathy is a fraud? I’ll take my chances with the later. And even then, I am open-minded, as a true skeptic should be, about what is actually the case. The fact is that no one can give anything approaching a satisfactory account. Of course, logically, it is possible that there is indeed something that “we haven’t though of” but is this the basis on which we should rest public policy? I think not.

Am I giving an impression of being afraid of my world view being challenged? Maybe. But I should stress that I am not opposed to research into HOW homeopathy works. What is being done now is research into WHETHER homeopathy works as compared to placebo or no treatment. The current practice assumes, on nothing more than the good faith of people like Dr. Malik, that there is anything there to compare in the first place.

Should we proceed with clinical trials of fire walking, blood-letting, voodoo, and black magic as alternative treatments? How about prayer and the healing touch? These have the same, if not greater, plausibility. Should we spend public funds on subsidizing people’s misguided decisions to take these “therapies” as alternatives to conventional medicine? If being grounded in reality is not a fundamental test for taking something into consideration, then anything and everything goes.

I don’t understand the point. If the insurer can afford it, then let it support any medication that the patient/physician thinks will help. Of course, at that point, the question is whether the other premium payers are paying too much.

There is always rationing. That must be the case when it comes to expensive and unusual (traditionally unaccepted) treatments. It is probably also the case in which the marginal cost of a short-term harm-prevention is hugely expensive.

The ethical question has to be what the insurer may charge its premium payers for drugs. If the insurer is a private insurer, the answer lies in the market for its product. If the insurer is the govenment, the answer lies in its duty to the taxpayers to make a rational decision as to how much the taxpayer will be charged for particular drugs.

Homeopathy is controversial. The public insurer should treat the determination to pay for homeopathic (or naturopathic, etc.) drugs as a political question, and the decision should be public and well-debated.

In response to Dmitri: I came in in support of trials because I didn’t have any particular reason to believe that those mentioned by Dr Malik were publicly funded, and you seemed to be reacting to those studies. Otherwise I think we are basically in agreement. Of the alternatives you mention, probably my favourite is “the healing touch”, because I don’t think it necessarily involves false beliefs. More generally, in addition to the positive psychology / meditation /self-hypnosis approaches I’ve mentioned previously, I think any kind of ritual (particularly those that don’t cost anything, involve any kind of exploitation or deceipt, and don’t harm the environment) that people associate in their minds with healing is likely to be a positive self-fulfilling prophecy and therefore strongly to be encouraged. “The healing touch” probably falls in this category, provided we indeed see it as a complement to, not as a substitute for, “conventional” treatments.

Dennis’s perspective from across the ocean is an interesting one, particularly the analogy of government as insurer. I’m not sure that’s really how most Brits (including myself) view the NHS though. But it provokes me to make a more general point, which is that I think we in the UK could learn a lot from health systems in other countries (including Belgium where I live) where there seems to be a bit more fluidity between the public and private sector. I may be wrong about this, but one of the problems I perceive with the NHS is that there is very little private money going into it. An insurance-based approach (where the patient pays a proportion of routine, small expenses) would helps to solve this. I often wonder why in the UK we take a Marxist position on health while following largely free-market principles on other issues.

There is no homeopathy dilemma at all, not in Brasil and not anywhere else in the world. The allegations that homeopathy was no better than a placebo-effect (or imagination) couldn’t be further from the truth. Firstly, each remedy acts differently. Secondly, these remedies cause test symptoms in test persons and, thirdly, homeopathic remedies cause a physical aggravation reaction in the patient. As long as the patient is repertorised, these remedies will work reliably. While being treated with homeopathic remedies, it is indispensable to avoid caffeine (coffee, tea, dark chocolate etc.), medicinal herbs (infusions etc.) and mint and menthol (toothpaste which contains menthol, mouthwash etc.)

A German Homeopathy Journal (Homöopathie-Zeitschrift II/09) reports on a fertility study which was carried out at the University Clinic of Heidelberg in the 1990s. The baby-take-home-rate for patients treated with classical homeopathy was 28.5% and for the conventionally treated hormone-therapy group 9.5%. Expenses and duration of therapy were 2,010 DM (Deutsch Mark at that time) / 4.8 months for the homeopathy group and 23,323 DM / 16.5 months for the hormone-therapy group. This study was supported by the German Carl-and-Veronika-Carstens-Foundation.
Hormone therapy group: 21 women, 6 pregnancies, 4 miscarriages
Homeopathy group: 21 women, 6 pregnancies, 6 babies given birth
Classical homeopathy resulted in an equal number of pregnant women, compared to the hormone-therapy group.

The latest issue of Homöopathie-Zeitschrift discusses the treatment of disabled children. Homeopaths employ Hahnemann’s miasm-theory and repertorisation of the patient to find the correct remedy. An alternative practitioner observed that her patients developed well with the remedies; babies learned to crawl, older children to communicate, and some could even go to school and learn. When the chosen remedy ceased to work and they needed it again, they would temporarily relapse to their old passive behaviours. One family had a healthy baby, and, after the obligatory vaccinations, they now have a handicapped child.

As to the ridiculous demand that homeopaths should be paid very little, I have to say that they don’t earn much anyway. They earn much less than any medical specialist who switches on an appliance to take a minute or two to (mis)diagnose a patient. If you have questions after the examination, the “specialist” is gone, leaving the discussion of the results to somebody else. Homeopaths have opted to learn homeopathy even though they earn much less because they have realised that it’s a very good way to help their patients. Having trained as doctors or alternative practitioners AND having completed training in homeopathy, they have a profound knowledge of medical issues.

Those people who attempt to oust homeopathy from the healthcare services so that it can be replaced by allopathy act irresponsibly. It is a relief to find out that Edzard Ernst has never completed any courses in homeopathy at all.

Some issues that have been debated in Germany this year:
– absurdly expensive cancer remedies that have turned out to be ineffective.
– 17,000 patients estimated to die every year in German hospitals due to mistakes that doctors make. The real figure is expected to be higher.
– too many drugs with too many dangerous side-effects given to the elderly.
– how pharmaceutical firms manipulate studies in order to introduce drugs on the market that may not be safe.
– In the last days, three babies died due to an infusion that was contaminated with bacteria. This lead to a general debate on hygiene in German hospitals. Bacteria that are resistant to antibiotics seem to be a big problem.
The FDA also publishes information on drugs that had to be pulled off the market due to severe side-effects or even death of patients. One drug that caused the death of more than 100 children was a simple coughing medicine.
So even if allopathy may be necessary at times, it is not always safe. Homeopathy can help with acute and chronic, even serious, health problems. It cannot regrow bones or lost tissue. It cannot replace the surgeon but it can support the healing process. Homeopaths will also prescribe antibiotics if the situation is serious enough and they also send patients to see specialists to confirm or establish a diagnosis. If homeopathy is successful, allopathic drugs can be reduced or discontinued.

“So even if allopathy may be necessary to times, it is not always safe.” I don’t think anyone would disagree with that.

“Homeopathy can help with acute and chronic, even serious, health problems.” Yes it can. So can other placebo-based remedies. The question is whether there is any effect that is NOT due to a placebo effect, and if so (following Dmitri’s comments) what possible mechanism there could be for this given that the actual theories that have inspired homeopathy are completely incompatible with our scientific worldview. Was the Heidelberg study placebo-controlled? If so, has it been included in any meta-analyses, and has it been subject to critical review? If not, why should we pay any attention to it given the multitude of studies that have?

To say something about the headline of this blog: If the NHS makes their own remedies, they have to be made strictly in accordance with the instructions that Hahnemann gave. If pellets or tablets do not contain homeopathic remedies, due to a faulty production process or because it was done deliberately, the patient will get nothing instead of a remedy, and thus his health will be unnecessarily put at risk. Also, if the NHS think – and apparently they do, thanks to the misinformation campaign – that the placebo-effect is behind all this, it will gravely undermine the patients’ trust in the medicines and doctors and whether patients are taken seriously by their GP at all. Now that would be real quackery and reduce the quality of treatment on the NHS.

The problem is that nowadays you cannot simply say: Try homeopathy.
On homeopath does Hahnemann, the other Sankaran.
Some homeopaths push against a patient’s arm (kinesiology), test their pulses or even use a pendulum to “find” the remedy and spare themselves the tedious repertorisation process.
Some use cat combos and grass mixtures against allergy while Hahnemannians would opt for the miasm-theory.
Some prescribe a whole bunch of remedies at once which is wrong because it should only be one or two (if they act together) remedies at the same time. Others have done a weekend-course and still put on their sign that they do homeopathy.
There are homeopathic mixtures on the market that use substances that would in their original form be beneficial (such as chamomile)while the original substances of classical homeopathic remedies are poisonous and thus counter the patient’s symptoms.
And, last but not least, there was the absurd idea that duck liver might help against swine flu.

In classical homeopathy, the original substances of the remedies would cause certain symptoms in a human being, including the psyche. Those patients who already have those symptoms get the respective remedy. This seems logical and straightforward. I have found it to work many times.

Everything else doesn’t but calls itself homeopathy, too. Forget about the placebo-effect. If it’s not done correctly, NOTHING, will happen, never mind our “imagination”. I have experienced that, too. I must add that I do not know enough about the Sankaran-method to be able to evaluate it. However, this method CAN lead to misinterpretations of the patient. Back to the roots is all I can say to anybody practicing homeopathy.

I would like to give a brief example of what an aggravation reaction looks like when you take a remedy which is in line with the patient. These are my personal experiences. Remember, each remedy works differently, reinforcing one symptom at a time:

Pulsatilla: Tiredness that wants to give in to sleep. My traffic accident knee felt numb and swollen but when I touched it, it wasn’t. I couldn’t move my leg for a while. A feeling as if my feet couldn’t carry my body. This lasted a few seconds. (I was seated at the time). Back to knee numbness. The remedy reinforces a symptom, let’s go and then reinforces it again later, albeit with less intensity. A couple of days later several areas of my back were hurting, one at a time. This lasted for a weekend. Ever since then I haven’t had back pain although I have to sit at work and also posted many comments on homeopathy in forums after work. I woke up one morning, covered in sweat which is one of the symptoms of the remedy but very unusual for me.
The middle finger of my left hand hurt. The next morning it went from swollen to not swollen twice than turned swollen and red before the problem disappeared. Then, in the afternoon, I couldn’t make a fist with my left hand. All my fingers were stiff as if I had arthritis (which is a health problem in my family). The right hand was not affected. A quarter of an hour later it was all over, and I could move my left hand as if nothing had happended.

Arsenicum album removed my chronic exhaustion. The aggravation, of course, was exhaustion. When I discontinued this remedy with a coffee after 4 weeks, after work the next day I collapsed on the sofa and had to sleep for 3 hours. I took the remedy again on the same day and left it to work for three months. Now I am no longer exhausted.

Two days after taking calcium carbonicum I got rhinitis and serval kinds of headaches all at once. This lasted for about a week. I am currently working my way through the miasms which will take about 2 years. Since I started homeopathic remedies I haven’t been a single day off work due to illness. Last year, I was ill frequently and not due to minor problems. I know how classical homeopathic remedies act. If I was given a placebo, I would notice. Diagnoses and allopathic treatment are left to my GP but I haven’t been to see her this year at all. These are examples of what homeopathic remedies can do if people would just let them.

Although I disagree with much of this last comment, I think it suggests a legitimate further critique of Steve’s initial idea. If the suggestion is indeed for the NHS to make its own homeopathic remedies, then we need to have some agreed definition of what constitutes “homeopathic”. Is Steve seriously suggesting that the NHS, in its preparations of the remedies, stick rigidly to homeopathic principles and techniques? If so, which ones? The original ones suggested by Hahnemann? Apparently there are different schools of homeopathy: looks like you might be getting into a hornet’s nest here.

As a more direct response to robinsfeather: I am a passionate believer in the placebo effect. I believe that psychology plays a hugely important and sometimes amazing role in influencing physical health. This is extremely well researched. I am also a passionate believer in the scientific method. Despite the many drawbacks with various forms of conventional medicine, or “allopathy”, they are subject to extremely rigourous tests using the same scientific method that has allowed us to develop such a sophisticated knowledge of the laws of the universe that we can do things like fly planes and communicate with each other via the internet. The more limited testing to which homeopathic remedies have been subjected so far fail to provide convincing evidence that there is an effect above placebo.

You say that the idea that giving patients remedies based on “original substances” that cause the same symptoms that the patient is suffering seems logical and straightforward. Why? Surely the “allopathic” principle: that you should give a patient something that has the opposite effect than the symptoms the patient is displaying, is far more logical and straightforward. If someone is drunk, give them coffee, not more alcohol.

Obviously something is working for you at the moment, so keep up with the remedies; but in the mean time do not dismiss out of hand the possibility that a placebo effect may be at work.

After Dmitri’s reaction to the discussion, I thought about posting a comment (actually, I draw one); but then I retreated. Then, a strong defense to homeopathy has arisen in the front. That reinforce my conclusion that, independently of my personal convictions that homeopathy (theoretically and clinically) doesn’t have solid and reasonable scientific support, and even if I am (and Steve Clark, Peter Wicks, Dmitri and almost all the others – if I don’t misinterpret them) are right in agreeing with that, we don’t have any good political reasons to forbid and, hence, not accepting its provision by the national health systems. After all, it is reasonable for people to have rights to alternatives, out of respect for their beliefs or convictions (provided GOOD FAITH and preserving informed consent). But those alternatives can only be offered as options; authorities would be wrong if they choose homeopathy in substitution of conventional medicine and other scientifically well supported health care practices. Even if homeopathy treatments would be cheaper, it doesn’t follow that authorities should offer them in substitution to the possibly more expensive conventional therapies (this reinforce Peter Wicks’ comment above – I agree with him). Anyway, even in case of being nothing more then mere *placebos*, the fact is that homeopathy and conventional medicine (or allopathic medicine, if we please) are incompatible practices. They are rival views of medicine. I know that there are physicians using both; but they cannot present a coherent defense for that eclectic practice. Patients must know that they are different. Anyway, we can live with both. The only restriction is that if some practices were to be proved by STRONG evidences as harmful, they must be forbidden. Here we must choose a criteria, and evidence-based medicine is the only one that is, today, reliable for the most part or us. I don’t see how Homeopathy could afford other methodological criteria also useful for guiding authorities.

To say something about the headline of this blog: If the NHS makes their own remedies, they have to be made strictly in accordance with the instructions that Hahnemann gave. If pellets or tablets do not contain homeopathic remedies, due to a faulty production process or because it was done deliberately, the patient will get nothing instead of a remedy, and thus his health will be unnecessarily put at risk. Also, if the NHS think – and apparently they do, thanks to the misinformation campaign – that the placebo-effect is behind all this, it will gravely undermine the patients’ trust in the medicines and doctors and whether patients are taken seriously by their GP at all. Now that would be real quackery and reduce the quality of treatment on the NHS.

The problem is that nowadays you cannot simply say: Try homeopathy.
On homeopath does Hahnemann, the other Sankaran.
Some homeopaths push against a patient’s arm (kinesiology), test their pulses or even use a pendulum to “find” the remedy and spare themselves the tedious repertorisation process.
Some use cat combos and grass mixtures to treat allergy while Hahnemannians would opt for the miasm-theory.
Some prescribe a whole bunch of remedies at once which is wrong because it should only be one or two (if they act together) remedies at the same time. Others have done a weekend-course and still put on their sign that they do homeopathy.
There are homeopathic mixtures on the market that use substances that would in their original form be beneficial (such as chamomile)while the original substances of classical homeopathic remedies are poisonous and thus counter the patient’s symptoms.
And, last but not least, there was the absurd idea that duck liver might help against swine flu.

In classical homeopathy, the original substances of the remedies would cause certain symptoms in a human being, including the psyche. Those patients who already have those symptoms get the respective remedy. This seems logical and straightforward. I have found it to work many times.

Everything else doesn’t but calls itself homeopathy, too. Forget about the placebo-effect. If it’s not done correctly, NOTHING, will happen, never mind our “imagination”. I have experienced that, too. I must add that I do not know enough about the Sankaran-method to be able to evaluate it. However, this method CAN lead to misinterpretations of the patient. Back to the roots is all I can say to anybody practicing homeopathy.

I was unaware that there were different typed of homeopathy. The NHS’s argument for funding homeopathy, which I endore, is one that appeals to choice. Therefore, it seems that the NHS should suport all of the main sorts of homeopathy, provided that it is cost effective to do so.

Marco, I would like to understand better your position on this issue. In an earlier comment you proposed “good faith and…informed consent” as conditions for accepting provision of homeopathy as part of a publicly-funded health system. But what does this mean in practice?

Let me give a concrete example with two alternatives.

In the first alternative, a patient is offered a homeopathic remedy by a doctor who sincerely believes, in spite of the evidence, in its efficacy independent of any placebo effect. Then, clearly the condition of “good faith” is fulfilled as far as the doctor is concerned, but is the condition of “informed consent” fulfilled? And how do we feel about having doctors working in a public health system whose beliefs are not based on evidence?

In the second alternative, the doctor knows (or more precisely believes, because this is what the evidence overwhelmingly suggests) that the efficacy of the treatment relies entirely on the placebo effect. He then has three options. One is to pretend that it efficacy is based on something else (e.g. the underlying theories being true). Then clearly we have neither good faith nor informed consent. A second is to explain very clearly the doctor’s belief to the patient. Then we have both, though in some cases (I would guess not in all however) this will undermine the efficacy of the treatment. A third is for the doctor to imply that the treatment is effective but without explaining why. After all, doctors don’t generally give patients a lecture on chemistry when they give us conventional treatments. Why should they give us lectures on the placebo effect? But then do we have good faith and informed consent?

I would like to supplement my previous comment with a more general comment about the nature of our discussions on this blog.

I am attracted to this blog for various reasons, but principally the combination of (i) a (supposed) focus on the future of humanity (I say “supposed” because I base this supposition essentially on the fact that it takes place on the future of humanity institute’s website), and (ii) the opportunity it provides to bring logical analysis and philosphical perspectives to current affairs.

What would make it even more interesting for me, however, would be if more effort was made to distinguish between empirical issues (such as whether or not the effectiveness of homeopathic remedies is entirely due to the placebo effect) and the basic moral choices that underlie the positions being taken. In the case of Steve’s original post on this specific issue, one of those “basic moral choices” seems to be that public health providers should not be paternalistic. But apart from the fact that it is not immediately obvious what constitutes “parternalistic” in this context (isn’t the whole idea of public health provision to some extent paternalistic?), it is also not clear to me to what extent this is supposed to be a fundamental moral choice, or a principle that is derived from more fundamental considerations.

It is, of course, up to the site managers and authors of the posts on this blog to decide whether to rise to this challenge, but having commented extensively now over a period of a few months I thought it might be both useful and legitimate to make a more direct suggestion on how I think the quality of these discussions could be (from my perspective of course) improved.

Following widespread interest in this blog topic I was invited to participate in a debate on NHS funding for Homeopathy on the BBC Radio Ulster program ‘Sunday Sequence’. Sunday Sequence is presented by William Crawley and the other participant in the debate is Terry McGuire, a specialist in pharmacy at Queens University Belfast.

Peter. Thanks very much for asking me those questions. Excuse-me for the delay. I had some particular problems and, anyway, the question is not easy. Actually your question made me think a while for a question: what we mean after all by “informed consent”? Since the response for that question would be essential for dealing with the first alternative, let me begin with the second. Doctors are aware that some *treatments* have good effects because of the placebo effect. Placebo effect can be attained with a placebo *drug*, but it can be also attained, intentionally or not, by treatments with a drug with known medical effect (a placebo effect can explain why some medications attain better results in patients, for example, who trust their doctors than in patients who don’t). In this case, the placebo effect seems to enhance the regular effect of some accepted treatment (in other words, increasing its probability of success).
Nevertheless, the use of placebo treatments is viewed negatively by modern bioethics in both situations. Not surprisingly, if the placebo effect is attained without intention, the doctor is not viewed as liable for it. But if the placebo effect was intentionally aimed, the doctor has actually deceiving his patient. In this case his paternalism should be justified by reasons. But there are few situations where paternalism is accepted today, but not without discussion (see for example the case reported by Tom Beauchamp and James Childress in their PBE, the Talvin/Elavil case). Even in pediatrics and with elderly patients we don’t use anymore placebo treatments, at least not intentionally. Anyway, probably psychiatrist are more prone in accepting that practice. But I don’t see how the second alternative could be applied to homeopaths. They don’t see their medications as a kind of placebo-treatment. It would be a good question if the stances implied by the second alternative can be accepted as ethical stances of administrators and specialists in social medicine commanding the public health care system. I think that is one of the possibilities suggested by Steve’s post. Anyway, it would be paternalistic, not a political decision favoring patient’s choice.
The first alternative depends on what we mean by “informed consent”. I see medical practice and the practice of obtaining consent as a persuasive art (in Aristotelian sense). Persuasion depends for its efficacy mainly in trust (and a good reason in that there are a lot of technical premises implied actually hidden). I think we should rather think “informed consent” as a cluster of patient’s rights than a result of a practical reasoning (or “dialectic”, following here also Aristotle) – the practical reasoning is actually made by the physician. One of those rights is the right of refusing a medical prescription. This right implies being informed. But I think your question is a very good one, for there are situations when the information is faulty and there are situations where they simply are not clearly displayed (see, for example, the case of psychoanalysis). Probably the last situation include homeopathy. Homeopaths usually don’t reveal the supposed secrets of their art for their patients (especially in the case of the *unicists* – how they could if the treatment is an unique solution to an unique patients?). Thinking about that I concluded that we must think informed consent in a most vague or loose sense, implying that the doctor must explain his broad reasons to his patient and ask for consent. Patients must consent them in the best informed way, but that *best way* doesn’t imply offering evidences following a evidence-based concept of “evidence” (for there are a lot of situations where it would be simply impossible, since they simply don’t exist).

I see the debate has raged on. The faithful and the devout have risen to close ranks.

I would like to dial things back a bit and ask the obvious question. On what grounds are we justified in considering a placebo to be treatment at all? The devout and the zealous notwithstanding, homeopathy is, at best, placebo in a vial (a claim I take with a pound of salt). But has there ever been an actual medical doctor (as opposed to a “doctor” of homeopathy) who has prescribed something that he knows to have no actual effect beyond placebo. As far as I am aware the placebo effect is primarily concept from in biomedical research, used in comparative studies (Treatment X, vs. Placebo vs. No Treatment). Never has it been considered as an actual treatment alternative. Nor would we want doctors knowingly prescribing placebos as treatments. Do you go to your physician for a drug pill or for a saccharin pill? I would be baffled by anyone who would disagree with this.

Many thanks to Marco for these important reflections on the nature of informed consent. It’s indeed a complicated issue and I certainly don’t profess to be an expert on the subject, but I think your comments contain a lot of common sense. In particular you are certainly right to emphasise the critical role of trust, and also the impossibility (or at least impracticability) of providing concrete evidence for every treatment.

In response to Dmitri;:
“has there ever been an actual medical doctor…who has prescribed something that he knows to have no actual effect beyond placebo”.
Does that include hospital doctors? Because if so they do it every day, in the form of a saline drip posing as morphine. (It’s standard practice to alternate morphine-based painkillers with sodium chloride, without informing the patient. In this way the placebo effect is harnessed to the benefit of the patient. I have witnessed this in the case of a loved one recovering from an operation (I happened to notice NaCl on the supposed morphine). I declined to inform her, of course. (A question for Steve: does this count as paternalism?) So in this case at least, doctors do prescribe placebos as alternatives. In the case of homeopathy I believe the placebo effect is very well researched (so no need for the pound of salt). The more general principle is: if you believe something will help, then it probably will.

One thing I find a little disappointing from this debate so far is the lack of interest in the concept of “placebo without deceit”. If we know (and we do) that faith can work wonders, then should we not be harnessing its power? I am convinced (also from my own experience: I don’t know if this puts me in the category of “the faithful and the devout”) that it is possible to do this without actually deceiving oneself or anyone else. If we value cost-effective treatment (and I suppose we do), then should we not be paying a bit more attention to this issue?